Provider Demographics
NPI:1871540088
Name:SALLOUM, ELLIS J (MD)
Entity type:Individual
Prefix:DR
First Name:ELLIS
Middle Name:J
Last Name:SALLOUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:ELLIS
Other - Middle Name:J
Other - Last Name:SALLOUM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:215 N SAN SABA STE 301
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78207-3164
Mailing Address - Country:US
Mailing Address - Phone:210-615-6626
Mailing Address - Fax:210-477-0279
Practice Address - Street 1:8115 DATAPOINT DR STE 200
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3745
Practice Address - Country:US
Practice Address - Phone:210-615-6626
Practice Address - Fax:210-477-0279
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60941287208600000X, 2086S0129X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2147693Medicaid
LAH55298Medicare UPIN